Welcome to our Practice!
Please take a few minutes to complete the following information so we can better care for your dentistry needs.
Today's Date
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Month
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Day
Year
Date
Patient Full Name
First Name
Last Name
Patient Date of Birth
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Month
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Day
Year
Date
Is this your child's first visit to the dentist?
Parent/ Guardian's Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/ Guardian's Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Who may we thank for referring you?
Has any other family member been a patient of this practice?
Dental History
Previous Dentist Name
Date of Last Visit
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Month
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Day
Year
Date
Date of last complete full mouth x-rays
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Month
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Day
Year
Date
Is your child currently experiencing any of the following dental concerns? (Check all that apply)
Toothache
Sensitive Teeth
Bleeding Gums
Pain or Clicking in the Jaw (TMJ/TMD)
Loose Teeth
Extra teeth
Tooth grinding/Clenching
Blisters on Lips/Mouth
Any Teeth Extracted
Chewing difficulties
Severe Head and or Facial Injuries
Missing teeth
Speech Difficulties
Prone to cavities
Jaw locking on opening or closing
Dry mouth
Are you currently experiencing dental pain or discomfort? If yes?
Are your teeth sensitive to hot, cold, sweets, or pressure?
Does the patient suffer from sleep apnea or snoring?
What if anything, are you looking for in a pediatric dentist?
Please check any of the following that may describe your child's attitude toward dentistry. (Check all that apply)
Cooperative
Excited
Friendly
Shy
Anxious
Frightened
Stubborn
Uncooperative
Do you have any known allergies or medical conditions? If yes, please provide details:
Are you currently taking any medications? If yes, please provide details:
Do you give consent for a dental screening and necessary treatment?
Yes
No
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Medical History
Physicians Name
First Name
Last Name
Date of Last Visit
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Month
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Day
Year
Date
Is the patient currently under medical treatment?
Is the patient taking any medications?
Has the patient ever had any serious illness and or operations?
Has the patient ever had allergic reactions to any drugs or medications? If yes, Which ones?
Is the patient allergic to Nickel or Latex?
Please check the box for each medical condition that applies:
Hyper activity (ADD/ADHD)
Thyroid problems
Bed wetting
Tonsils/Adenoids Removed
Asthma/ Hay fever
Frequent Headaches
Sleep study conducted
Bone Disorders
Speech impairment
Artificial heart Valves
Fainting/ Dizzy Spells
Liver disease
Kidney deseas
Pneumonia
Nervous Problems
Arthritis/ Rheumatism
Sinus Problems
Mood Swings
Epilepsy
High Blood Pressure
Heart Problems
Motor Difficulties
Radiation Treatment
Tuberculosis
Restless Sleep
Frequent Colds
Loss of Interest
Diabetes
Cancer
Bleeding Excess
Stroke
Stomach Ulcer
Hearing Issues
If other, please describe below:
Primary Dental Insurance
Person reponsible for Account
First Name
Last Name
Relationship to Patient
Date of Birth
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Month
-
Day
Year
Date
Soc. Security #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Home Number
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Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Responsible Party Employed By...
Occupation
Insurance Company
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone
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Area Code
Phone Number
Subscriber ID#
Group ID #
Additional Dental Insurance
Person responsible for Account
First Name
Last Name
Relationship to Patient
Date of Birth
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Month
-
Day
Year
Date
Soc. Security #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Home Number
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Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Responsible Party Employed By...
Occupation
Insurance Company
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone
-
Area Code
Phone Number
Subscriber ID#
Group ID #
HIPPA Compliance Disclosure
Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by the OSHO, the CDC and the ADA. I Understand that the information I have given is correct to the best of my knowledge, and that it will be held in the strictest confidence. I authorize release of any information regarding my treatment to my dental/ medical insurance company. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my dentist of any changes in my medical/dental health.
Signature
Date
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Month
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Date
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